Get Ww Cobra Acct Change Lexington Form

Completing the Ww Cobra Acct Change Lexington Form online is crucial for updating your COBRA coverage details, whether adding or removing dependents. This guide provides clear instructions to ensure you fill out the form accurately and efficiently.

Follow the steps to fill out the Ww Cobra Acct Change Lexington Form online.

1. Click the ‘Get Form’ button to obtain the form and open it in your document management tool.
2. Begin by entering the primary qualified beneficiary information. Ensure that all fields marked are filled in correctly. This includes the last name, first name, social security number, address, city, state, zip code, and email address if it’s a new address.
3. In the certification and authorization section, review the statement and ensure that the information provided is accurate. Sign and date the form to confirm your acceptance of the WageWorks User Agreement.
4. Select the request type in the designated section. Indicate whether you are adding or removing a dependent or yourself from your COBRA continuation coverage.
5. For adding or removing a dependent, fill in the necessary fields for each individual, including their name, social security number, effective date, date of birth, dependent relationship, and choose their coverage type (medical, dental, vision, etc.). Include the reason for the change.
6. If you are terminating your COBRA coverage, fill in the termination request section by specifying whether you want to terminate all benefits or only specific ones, and provide the effective date.
7. If applicable, fill in the Medicare entitlement notification section by providing the member’s name and the effective date of their Medicare coverage.
8. If necessary, correct any information in the update sections provided for the name, social security number, or date of birth.
9. Once the form is complete, save your changes. You can then choose to download, print, or share the form as needed.

Complete your Ww Cobra Acct Change Lexington Form online today to ensure your coverage details are up to date.